Smilesonus.info

MEDICAL HISTORY QUESTIONNAIRE
□ Mr. □ Miss. □Mrs. □ Ms. □ Dr.
IN CASE OF EMERGENCY, WE SHOULD NOTIFY
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__________________________________________ Relationship: _______________________________
Date of Birth (Day/Month/Year): ___ / ___ / ____
Address (Home): ____________________________ Name of Family Doctor
__________________________________________ __________________________________________
City: ______________________________________ Phone Number or Address:
Province: ___________ Postal Code: ____________ __________________________________________
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Address (Work): _____________________________ (1) Name of Medical Specialist:
__________________________________________ __________________________________________
City: ______________________________________ Area of Specialty: ___________________________
Province: ___________ Postal Code: ____________ Phone Number: (___) ____ - _______
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Area of Specialty: ___________________________
The fol owing information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The medical professional wil review the questions and explain any that you do not understand. Please fill in the entire form.
1. Are you being treated for any medical condition at the present or have you been treated within the past
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3. Has there been any change in your general health in the past year? If yes, please explain.
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To be completed by Medical Professional Only:
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes,
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5. Do you have any al ergies? If you answered yes, please list using the categories below:
a) Medications ___________________________________________
b) Latex/Rubber Products ___________________________________________
c) Other (e.g. hay fever, foods) ___________________________________________
6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.
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7. Do you have or have you ever had asthma?
8. Do you have or have you ever had any heart or blood pressure problems?
9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart
(i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart
10. Do you have a prosthetic or artificial joint?
11. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS,
HIV infection, radiotherapy, chemotherapy?
12. Have you ever had hepatitis, jaundice or liver disease?
13. Do you have a bleeding problem or bleeding disorder?
14. Have you ever been hospitalized for any il ness or operations? If yes, please explain.
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15. Do you have or have you ever had any of the following? Please check.
To be completed by Medical Professional Only:
16. Are there any conditions or diseases not listed above that you have or have had? If so, what?
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17. Are there any diseases or medical problems that run in your family?
(e.g. diabetes, cancer or heart disease)
18. Do you smoke or chew tobacco products?
19. Are you nervous during dental treatment?
20. For women only: Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
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To the best of my knowledge, the above information is correct:
PATIENT/PARENT/GUARDIAN SIGNATURE: ___________________________________________________
DENTIST SIGNATURE: ___________________________________________________
DOCTOR/NURSE INITIALS: ___________________________________________________
To be completed by Medical Professional Only:

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